Anger, Irritability and Mood Swings

After a brain injury, it is common to feel upset or angry more often than you did before it happened. It is normal to experience a range of emotions as you face challenges resulting from your injury. However, if you find that you cannot control feelings such as anger or other strong emotions, it can be hard for you and those around you. Many people find that they are more irritable; some have trouble controlling their temper or find that their emotions fluctuate between extremes.

• “I’m on a short fuse.”
• “I seem to cry for no reason.”
• “It’s like being on an emotional rollercoaster.”

If any of these issues are affecting you, we hope you will find this information useful.

We have written it to help you understand more about the ways a brain injury can affect how you feel and act. We also give suggestions for practical things you can do.

Suggest to friends, family or other people supporting you, to read this page also. There are tips for what they can do below.  If, after reading this page and trying the tips, you do not see any improvements, getting professional help may be beneficial. You will find contact details for a range of relevant professionals under Help and Information.

The brain’s role in managing our emotions

Our brains control all our emotions, impulses and behaviours. The way our brains generate emotions and control them is very complex. Certain parts of the brain are significant in being able to manage our feelings and behaviour. The Frontal Lobes (behind our forehead) act like a control centre. They play an important role in managing sudden urges (impulses) and influence what we do (behaviours) in response to the emotions we feel.

Our Frontal Lobes help us make fairly rational decisions even when we feel strong emotions. For example, if we are angry and have the impulse to hit someone, our Frontal Lobes tell us: ‘No – don’t! You might hurt them!’.

Frustration, anger, helplessness and depression – it took me a long time to get a hold on my emotions again. Relaxation and breathing exercises help, as well as valuable techniques I learned at Anger Management

Sue, Co Cork

What causes anger, irritability or mood swings after a brain injury?

Several things can work together to cause difficulties with managing mood swings, irritability or anger after a brain injury. The three most common are:

1. Direct damage to the brain
   If there is damage to parts of the brain such as the Frontal Lobes or other linked brain structures, they may not be performing their job managing your emotions as well as before. A brain injury may also exaggerate any personality traits or problems you had previously.
2. Your psychological reactions to changes following your injury.
   Coping with life after a brain injury can be challenging. Understandably, you may be going through a range of emotions such as disbelief, anger, regret, guilt or grief. You may be trying to come to terms with changes such as fatigue, disability, having to give up work or perhaps having less control over your life. All of this can cause a lot of emotional upheaval and unwanted stress.
3. Your environment
   Your emotional reactions are influenced by where you are (your physical environment) and who you are with (your social environment). Currently your social environment may include, for example, rehabilitation staff, family, friends, neighbours or perhaps colleagues.
   If you are in an environment that is busy or unfamiliar or where you feel your needs are not being met, this may make your stress levels go up. This can affect how you feel and act.

Anger and Irritability

After a brain injury, many people find they become irritated over small things that would not have previously bothered them, for example, being kept waiting for an appointment.

Many things can set off emotional responses like irritation. We call these triggers. These triggers will vary from person to person but there are some common ones that affect many people.

Professional advice may be helpful if you don’t see any improvement (see Help and Information below for contacts).

Common causes and triggers for anger and irritability

The environment	Noise or light. Too much activity or too many people. Lack of structure or routine. Unexpected change in your routine. New situations. Too many demands. Too much being expected of you by others.
Due to direct damage to the brain or to psychological reactions	Emotions such as embarrassment, shame, frustration, stress, fear, hurt, anxiety or sadness. Confusion. Loss of independence – for example, no longer being able to drive. Awareness of losses or loss of skills – for example realising you cannot do some things. Cognitive changes – for example, memory difficulties. Reduced ability to control impulses. Communication difficulties. Rigid thinking (not being able to see things from other people’s perspective). Changes in roles within the family or working.
Physical Issues	Pain Headaches Fatigue Poor sleep Hunger or low blood sugar Side-effects of medications Seizures (epilepsy) Problems with hearing or vision Greater effects now of alcohol or non-prescription drugs

What you can do about anger

• Think about what situations, events or feelings tend to set off your anger – these are your triggers. Write a list and try to avoid them as much as possible.
• Where you cannot avoid things that trigger your anger, practice ways of managing it – see Ways to manage your anger below for a list of practical suggestions.
• Ask your family, friends or others for their support. There are tips for them below.
• Get as much physical exercise as you can. Exercise allows you to release physical and emotional tension and to feel a sense of achievement. Ask your GP or physiotherapist what types of exercise they’d advise.
• Tiredness is a common trigger for anger and irritability. If fatigue affects you, try to avoid becoming over-tired. See the Fatigue and sleep page for more information and tips.
• If being hungry makes you more likely to be irritable, try to keep your blood sugar levels steady by eating regularly and having healthy snacks at hand.
• Discomfort, pain or headaches can exacerbate irritability and anger. Simple changes such as turning down lighting, trying a different sitting position or not getting too hot or too cold, may help. If not, contact your GP (see Getting professional help below).

Ways to manage your anger

 Tips for managing anger

1. Recognise the early signs of becoming angry

There are distinctive signs when anger is building up in the body. In order to control anger, it is important to learn to identify these early signs. They include:

• Breathing faster.
• Muscles becoming tense.
• Tightening your jaw.
• Sweating.
• Raising your voice.
• Clenching your fists.

Make an effort to notice these signs. Stop what you are doing. Try the steps that follow to help keep control of your anger.

2. Don’t stay in a situation that is making you angry. Move away, if possible, to allow yourself to calm down.

3. Try doing muscle relaxation or breathing exercises.

4. Try to distract yourself from whatever is making you angry – for example listen to music, read or go outside for some air, if possible.

5. Be aware that other emotions such as anxiety, embarrassment or not feeling in control, can trigger anger. If this is what happened, tell someone what you were feeling. Try to sort out whatever caused the feelings that lead to you becoming angry.

6. If getting frustrated when trying to solve problems sets off your anger:

• Stop what you are doing.
• Ask yourself:
  • Do you need to take a break or stop?
  • Do you need to try a different way to sort out the problem?
  • Would it help to ask someone to give you a hand?
• Is there a different way to communicate what you are trying to get across?

7. Remind yourself of the ways you know help to manage your anger by carrying a note card with bullet points written down.

Using the tips effectively

• Try out Tips 1-7 a few times to see which ones work for you. Use a notebook to keep track.
• Note the ones that work on a card. Laminate it and keep it handy.
• You will need to practice the tips a lot in order to make them effective in managing your anger.
• Use a note book.
• Write down what triggered your anger, how you felt, what you did to manage the anger and if it went well. Note anything you would do differently the next time.
• It may help to show your notes to someone you trust and ask for their point of view.

What other people can do about your anger

• Avoid trying to reason with someone when they are at their angriest. Give them space and time to regain control of their emotions.
• Acknowledge their feelings and try to help them to sort out whatever is causing the anger.
• If they are too upset to sort out the problem, directing their attention away from what caused the anger may be effective – for example suggest doing something else or getting some air outside, if possible.
• If there doesn’t seem to be any obvious reason why they were angry, ask them how they were feeling before the anger outburst. This may help them to pinpoint if some other feeling lead to their anger – for example, frustration, embarrassment or feeling under pressure.
• Stay calm yourself

When someone is having an anger outburst, try to focus on staying as calm as possible yourself. This is not always easy, of course, but it can help you avoid getting upset yourself.

If you stay calm, it may also help the other person to regain control.

Keep your body as relaxed as possible. Try to avoid sudden movements. Breathe slowly and fully. Once the person has started to calm down, talk quietly to them.

Mood Swings and difficulty controlling emotions

Changes in how we feel are a part of everyday life. It is normal to experience a range of emotions as you try to come to terms with having a brain injury. However, some people experience noticeable (and often very quick) changes in how they are feeling. These are known as mood swings.

Emotional lability

Some people who experience mood swings after their brain injury have what is known as Emotional lability. Emotional lability means a loss of emotional control or reduced control. It can cause unpredictable outbursts of laughing, crying or anger, for example. The emotions often come on very quickly and intensely but pass with little lasting effect.

If you are affected by emotional lability, you may find yourself laughing one moment and crying the next. This can be upsetting and embarrassing for you and people around you. However, understanding what is happening and learning to avoid things that trigger it, may help.

What causes emotional lability?

Emotional lability is caused directly by damage to parts of the brain that control emotions and impulses. If you have emotional lability, the outbursts are not something you can usually control. They are likely to be worse shortly after the brain injury. However, they usually become less intense over time and may go away entirely.

Often there is nothing specific that triggers a sudden outburst of emotion. However, there are a number of things that can make emotional lability worse. If you have anger outbursts, read the section above on the list of causes and triggers. Triggers for laughing or crying can include other people expressing strong emotions and emotional situations – for example, very sad or funny situations.

If you have emotional lability, there are three common ways it may affect you:

1. When the emotion you express reflects what you are feeling but it is exaggerated – for example, crying uncontrollably when you only feel a little unhappy.
2. When the emotion you express does not reflect what you are feeling – for example, crying suddenly without feeling sad or laughing without feeling happy.
3. When the emotion you express is the opposite to what you would expect in the situation – for example, laughing at a sad story.

What you and other people can do about your mood swings

• Ask friends and family to help you pinpoint what situations or events trigger your outbursts of emotion. Try to avoid these triggers as much as possible.
• Explaining to other people that your strong emotional reactions are directly due to your brain injury, may help them to accept what is happening and make allowances for you when you have an outburst. There are tips for what they can do below.
• Explaining simply to friends and family exactly how your brain injury affects you may help – for example: ‘Since I had my brain injury I cry a lot even when I’m not sad. Don’t worry, I will be fine in a few minutes.’.
• Some medications can help with the control of emotions. Talk to your GP about this.
• If your emotional outbursts are anger outbursts, read back over ‘Common causes and triggers for anger and irritability’ above and try to pinpoint any triggers for your anger. Try out the tips for managing anger above.

If, after their brain injury, someone you know is affected by emotional lability, their outbursts of laughing, anger or crying, can take a bit of getting used to. This is usually directly due to their brain injury and often there is nothing specific that triggers the outbursts.

Some things that may help are:

• Try to stay calm yourself. People who are prone to emotional outbursts find it harder to control themselves when other people become emotional.
• It is important to ask them what they want. If they want to be left alone for a while, respect their wishes.
• If you were talking about something that brought on the outburst, try changing the subject.
• Suggest they take some slow, full breaths.
• If you know the person well, a hug or a touch on the arm may be reassuring. This will naturally depend on your relationship with them and what they want.
• If anger outbursts are the issue, see ‘What other people can do about your anger’ above for specific tips on what you can do.

Getting professional help

In some situations, professional support may be useful to help you manage anger or mood swings following your brain injury.

• Contact your GP for advice.
• If pain or headaches are affecting your ability to manage your emotions, your GP can give advice on treatment options. They may offer treatment themselves and/or refer you for Physiotherapy, Occupational Therapy or to a specialist for management of your pain or headaches.
• Seeing a Psychologist experienced in the treatment of brain injury may also be helpful. They may suggest doing an assessment of your cognition (thinking and reasoning) and behaviour, and recommend strategies that can help with managing your emotions.
• If you have significant difficulty with emotional outbursts, your GP may suggest referring you to a Psychiatrist. The Psychiatrist may recommend medication to help manage your emotions.
• See Help and Information below for ways to contact the various professionals mentioned here.

• Many people have trouble managing emotions, including irritability and anger, after a brain injury.
• Several things can cause difficulties, including direct damage to your brain, your environment and your reactions to changes in your life.
• General tips such as taking plenty of exercise, not getting too tired or hungry and getting relief from pain or discomfort, may help reduce irritability and anger.
• People prone to emotional outbursts may have things which set them off or ‘trigger’ them. Getting to know your triggers is one of the key steps in managing these difficulties.
• However, if you have emotional lability (a loss of emotional control or poor control), there may be nothing specific that triggers an outburst.
• If you have difficulties managing anger, try to learn to spot the early signs of anger building up in your body. Then, practice steps to prevent the anger getting out of control.
• Getting professional advice may be helpful. Speak to your GP or other professionals involved in your care.

Psychologists

Headway offers free community-based brain injury assessment, psychotherapy and rehabilitation in Cork, Kerry, Limerick and Dublin.
t: 1800 400 478

Public psychologists: your GP or Public Health Nurse can refer you.
HSE t: 1800 700 700 or visit w: www.hse.ie

Registered private psychologists

Contact the Psychological Society of Ireland.
t: 01 472 0105 or visit w: www.psychologicalsociety.ie

Pain and discomfort may be relieved through Physiotherapy or Occupational Therapy. These are available through a referral from your GP to your local Health Centre.
HSE t: 1800 700 700 w: www.hse.ie

Private Physiotherapy and Occupational Therapy

Chartered Physiotherapists in Private Practice.
t: 01 402 2574 w: www.cppp.ie

Association of Occupational Therapist in Ireland.
t: 01 874 8136 w: www.aoti.ie